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Contractor Name: V & W Drillin <br />License #: 72 904 <br />Signature: 2.01VOL <br />Print Name: Karli Renae Stroing <br />, n <br />San J aquin County Environmental Health Department <br />WELL & BO ING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: j <br />P, Cflin Htti PERMIT SR #: <br />LICENSED QONTRACTORS DECLARATION <br />I hereby affirm that I am licensed u <br />Division 3 of the California Busine <br />d r the provisions of Chapter 9 (commencing with Section 7000) of <br />and Professions Code and my license is in full force and effect. <br />,0 <br />Expiration Date: 4/30/2022 <br />Title: Pr side <br /> Date: 91)(UP <br />WORKE S' COMPENSATION DECLARATION <br />i hereby affirm under penalty of perju ne of the following declarations: (check one) <br />I have and will maintain a ce ificate of consent to self-insure for workers' compensation, as 0 provided for by Section 3790 of the Labor Code, for the performance of the work for which this <br />permit is issued <br />I have and will maintain work <br />0 Labor Code, for the perforria <br />compensation insurance c r <br />Carrier: State Fund <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subj Ct t the wor rs' compensation law of California, and agree that if I <br />should become subject to worker 'co pensati n provisions of Section 3700 of the Labor Code, I shall <br />fohwi comply 4,ith those provisions. <br />ktfp PtiV <br />Print Name: Karli Renae Stroing <br />rs' compensation insurance, as required by Section 3700 of the <br />nce of the work for which this permit is issued. My workers' <br />er and policy numbers are: <br />Policy #: 9115022-20 Exp. Date: 10/2/2021 <br />Signature: <br />WARNING: FAILURE TO SECURE W R <br />SUBJECT AN EMPLOYER <br />ADDITION TO THE COST cF <br />AS PROVIDED FOR IN SECT! <br />ERS COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />0 CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />N 3706 OF THE LABOR CODE <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING <br />, <br />PE RMIT PLIC <br /> <br />A <br /> <br />TION <br />hereby authorize ov 4fr? <br />o uhoriZ ent <br /> <br />to sign this San Joaquin C unty W II & Borin PerMit Appliciaiion on my behalf. I und stand this <br />authorization is valid for one ye r an 's Ilinited to the vv9rk,planiclled on the front page of this application. <br />r <br />seditu rtz;r1 R to <br />Karli Reae Stroing <br />Name ut C-57 Licensed Authorized Representatire <br />E-ID 29-01 6-23-2015 Site Mitigation VVell Permit Application